Provider Demographics
NPI:1639520810
Name:MAK, SOPHIE
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:MAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-6526
Mailing Address - Country:US
Mailing Address - Phone:212-398-1709
Mailing Address - Fax:
Practice Address - Street 1:201 E 65TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6701
Practice Address - Country:US
Practice Address - Phone:212-879-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031902363A00000X, 363AM0700X
FLPA9109602363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9109602OtherMEDICAL LICENSE
FL017967300Medicaid
NY031902OtherNY PHYSICIAN ASSISTANT LICENSE